O'Sick, Alice OF QUEEN5BUTr
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QLJEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C3/4KNR
Fame A I I' e O1
5`(k Case#. L139
Date Of Cremation
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Time Cremation Started
Time Cremation CompleIed Cf'• ')0 4
Type of Container l('n.'��oc„ -A _
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12864
Cemetery Office: (518)745.4476,Crematorium: (518)745-4477
AudwAmbon to CWHI818
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate remains I
(Name) 0 (Sex)5 b%. St7l k`o
(Street) (City) (fie) (ZP
who died on I��� 20 C
at � 007
(Piece) (A )
Name
and Tess ng relative o7—
(Name) of person authorb"
O Ail Tz= r4
( )
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
1 represent that to the best of my womedge,the deceased(has)or no) ,defiix�ator,battery.battery paac.Parer
cell,radiowWe implant or radioactive devios in his or her body.(Circle
1 oer*that 1 have f A power and authorbafim to anaw for the cremation of the remmins aid to direct the disposition of the
cremated remains.that any personal possessions have either been removed or may be destroyed.and agree to protect,defend and
5gr
ve View Cren torkm fecal arty end all cairns and demands for toss or dMoges which may be made agaimt them
reason or with cr+e radon of said remainsasdirected.wrdedrer such detersardemandsareorarenotwholly
oundless .
(witness) (Address)
Signature and Address of R /' or Legal Representative)
C
Signed on this date:���`d 2
Dox"on of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as kBows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,dm&here
Revision:April 18,2007